IMPAIRED ADJUSTMENTS Nursing Care Plan

Impaired adjustments is a nursing diagnosis used when there's inability in the patient to modify lifestyle or his or her behavior in a manner of consistent with a change in health status.

Related Factors
Disability or health status requiring change in lifestyle.
Multiple stressors; intense emotional state.
Low state of optimism; negative attitudes toward health behavior; lack of motivation to change behaviors.
Failure to intend to change behavior.
Absence of social support for changed beliefs and practices.
[Physical and/or learning disability]

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Defining Characteristics
SUBJECTIVE:
Denial of health status change
Failure to achieve optimal sense of control

OBJECTIVE:
Failure to take actions that would prevent further health problems
Demonstration of nonacceptance of health status change



PLANNING
After 2 hours of nursing intervention, the patient will demonstrate increasing interest and participation in self-care, the patient will also develop ability to assume responsibility for personal needs when possible. The patient will also initiate lifestyle changes that will permit adaptation to current life situations. In addition, the patient will identify stress situations leading to impaired adjustment and specific actions for dealing with them and identify and use appropriate support systems.

INTERVENTIONS
- Assess the degree of impaired function. Perform a physical and psychosocial assessment to determine the extent of the limitation(s) of the current condition. Listen to the client’s perception of inability or reluctance to adapt to situations that are occurring currently. Survey (with the client) past and present significant support systems like family, church, groups, and organizations to identify helpful resources.

- Explore the expressions of emotions signifying impaired adjustment by client such as overwhelming anxiety, fear, anger, worry, passive and/or active denial.

- Identify the causative and contributing
factors relating to the impaired adjustment by listening to client’s perception of the factors leading to the present impairment, noting onset, duration, presence/absence of physical complaints, social withdrawal. Review previous life situations and role changes with client to determine coping skills used. Determine lack of inability to use available resources. You must also review available documentation and resources to determine actual life experiences, resources like medical records, statements by parents, relatives, friends and co-workers because in situations of a great stress, physical or emotional, the client may not accurately assess occurrences leading to present situation.

- Assist the client in coping/dealing with
impairment by organizing a team conference that also includes the client and ancillary services to focus on contributing factors of impaired adjustment and plan for management of the situation. Acknowledge client’s efforts to adjust by telling him or her, "You have done your best.” It lessens feelings of blame, guilt and defensive response. Share information with adolescent’s peers when illness/injury affects
body image because peers are primary support for this age group.

- Explain disease process/causative factors and prognosis as appropriate and promote questioning to enhance understanding. Provide an open environment encouraging communication so that expression of feelings concerning impaired function can be dealt with realistically. Use therapeutic communication skills such as active-listening, acknowledgment, silence, and I-statements.

- Discuss and evaluate resources that have been useful to the client in adapting to changes in other life situations like vocational rehabilitation, employment experiences, psychosocial support and services.

- Develop a plan of action with client to meet immediate needs such as physical safety and hygiene, emotional support of professionals and significant others and assist in implementation of the plan. It will provide a starting point to deal with current situation for moving ahead with plan and for evaluation of progress.

- Explore previously used coping skills and application to current situation. Refine and develop new strategies as appropriate. Identify and problem-solve with the client frustration in daily care. Focusing on the smaller factors of concern gives the individual the ability to perceive the impaired function from
a less-threatening perspective, one-step-at-a-time concept. Involve SO(s) in long-range planning for emotional, psychological, physical, and social needs.

Promote wellness, teaching and discharge considerations. Identify strengths the client perceives in current life situation. Keep focus on the present, as unknowns of the future may be
too overwhelming. Refer to other resources in the long-range plan of care (e.g., occupational therapy, vocational rehabilitation) as indicated.

- Assist client/SO(s) to see appropriate alternatives and potential changes in locus of control. Assist SO(s) to learn methods for managing present needs. Pace and time learning sessions to meet client’s needs. Provide feedback during and after learning experiences (e.g.,
self-catheterization, range-of-motion exercises, wound care, therapeutic communication) to enhance retention, skill, and confidence.

EVALUATION
After 2 hours of nursing intervention, the patient demonstrated increasing interest and participation in self-care, the patient also developed ability to assume responsibility for personal needs when possible. The patient also initiated lifestyle changes that will permit adaptation to current life situations. In addition, the patient identified the stress situations leading to impaired adjustment and specific actions for dealing with them and identify and use appropriate support systems.

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MATURATIONAL ENURESIS Nursing Care Plan

      So what's the meaning of maturational enuresis? Maturational enuresis occurs in children during night. It is when a child experience involuntary voiding while sleeping and it is not pathologic in origin. Do not use this diagnosis when enuresis results from urinary tract infection, constipation, epilepsy and diabetes. Instead, you can use this when enuresis is from small bladder capacity, failure to perceive cues with a maturational issue such as new siblings or school pressures. We provided one sample of nursing care plan for maturational enuresis below.

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ASSESSMENT:
Subjective:
"I always peed my bed every night," the boy said.

Objective:
(The boy is actually normal since this nursing diagnosis is not pathologic in nature.)

RISK FOR ADVERSE REACTION TO IODINATED CONTRAST MEDIA Nursing Care Plan

        This diagnosis is use if the patient is experiencing unintended reaction associated with the use of iodinated contrast media that can occur within seven(7) days after contrast media injection. Iodinated contrast media is infused to the client when the client will undergo radiographic diagnostic tests. Nurses caring clients scheduled for this test must be aware if the client has a higher risk for adverse events. Reactions can be mild and self-limiting to severe and self-limiting. Nurses in radiology department are responsible for assessing high risk clients. They review renal function status of the client prior to the procedure, monitoring signs of reactions and using protocols if indicated.

        We will provide a sample of nursing care plan for this risk for adverse reaction to iodinated contrast media, which is stated below:

ASSESSMENT:
Subjective:
"I have an allergy to iodine", the patient said verbally.

Objectives
- Records of past history of allergic reactions to iodinated contrast media.

DIAGNOSIS:
Risk for adverse reaction to iodinated contrast media related to history of allergy to iodinanted contrast media.

PLANNING:
After 1 hour of nursing intervention, the patient will be able to understand the need to report and describe the delayed reactions of iodinated contrast media.

INTERVENTIONS:
- Review the client history of allergic reactions to contrast media.

- Explain the delayed reactions of contrast media, advise the client and the family that a delayed contrast reaction can occur anytime between 3 hours to 7 days following the administration of contrast. Explain that delayed reactions may be cutaneous exantherm or commonly called widespread rashes, pruritus without hives, nausea, vomiting, drowsiness, and headache.

- Advise them to report any said reactions to the physician. If difficulty of swallowing or breathing occurs, immediately go to E.R.

EVALUATION:
After 1 hour of nursing intervention, the patient understood the need to report and described the delayed reactions of iodinated contrast media.

Note: Remember this contrast media reactions:
Mild reactions:
- Scattered urticaria
- Nausea
- Diaphoresis
- Pruritus
- Brief blenching
- Coughing
- Rhinorrhea
- Vomiting
- Dizziness

Moderate reactions:
- Persistent vomiting
- Facial edema
- Palpitations
- Diffuse urticaria
- Tachycardia
- Mild bronchospasm or dyspnea
- Headache
- Hypertension
- Abdominal cramps

Severe reactions
- Life-treatening arrhythmias
- Pulmonary Edema
- Death
- Laryngeal Edema
- Seizures
- Overt brochospasm
- Syncope

Nonidiosyncratic
- Bradycardia
- Neuropathy
- Nausea and vomiting
- Hypotension
- Cardiovascular reactions
- Sensations of warmth
- Vasovagal reactions
- Extravasations
- Metalic taste in mouth

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IMPAIRED PARENTING Nursing Care Plan

Impaired Parenting
Inability of the primary caregiver to create, maintain, or regain
an environment that promotes the optimum growth and development
of the child
Defining Characteristics
The home environment must be assessed for safety before discharge:
location of bathroom, access to water, cooking facilities,
and environmental barriers (stairs, narrow doorways).
Inappropriate and/or nonnurturing parenting behaviors
Lack of behavior indicating parental attachment
Inconsistent behavior management
Inconsistent care
Frequent verbalization of dissatisfaction or disappointment with
infant/child
Verbalization of frustration with role
Verbalization of perceived or actual inadequacy
Diminished or inappropriate visual, tactile, or auditory stimulation
of infant
Evidence of abuse or neglect of child
Growth and development challenges in infant/child
Related Factors
Individuals or families who may be at risk for developing or
experiencing
parenting difficulties
Parent(s)
Financial resources
Single
Addicted to drugs
Adolescent
Terminally ill
Abusive
Acutely disabled
Psychiatric disorder
Accident victim
Alcoholic

Child
Of unwanted pregnancy
With undesired characteristics
Terminally ill
With hyperactive characteristics
Mentally handicapped
Of undesired gender
Physically handicapped
Situational (Personal, Environmental)
Related to interruption of bonding process secondary to:
Illness (child, parent)
Relocation/change in cultural environment
Incarceration
Related to separation from nuclear family
Related to lack of knowledge
Related to inconsistent caregivers or techniques
Related to relationship problems (specify):
Marital discord
Stepparents
Divorce
Live-in partner
Separation
Relocation
Related to little external support and/or socially isolated family
Related to lack of available role model
Related to ineffective adaptation to stressors associated with:
Illness
Economic problems
New baby
Substance abuse
Elder care
Maturational
Adolescent Parent
Related to the conflict of meeting own needs over child’s
Related to history of ineffective relationships with own parents
Related to parental history of abusive relationship with parents
Related to unrealistic expectations of child by parent
Related to unrealistic expectations of self by parent
Related to unrealistic expectations of parent by child
Related to unmet psycho-social needs of child by parent

Author's Notes
The family environment should provide the basic needs for a child’s
physical growth and development: stimulation of the child’s emotional,
social, and cognitive potential; consistent, stable reinforcement to learn
impulse control; reality testing; freedom to share emotions; and moral
stability (Pfeffer, 1981). This environment nurtures a child to develop, as
Pfeffer (1981) states, “the ability to disengage from the family constellation
as part of a process of lifelong individualization.” It is the role of
parents to provide such an environment. Most parenting difficulties stem
from lack of knowledge or inability to manage stressors constructively.
The ability to parent effectively is at high risk when the child or parent
has a condition that increases stress on the family unit (e.g., illness,
financial
problems). “The phenomenon of parenting is relevant to many
disciplines, including nursing” (Gage, Everett, & Bullock, 2006).
Impaired Parenting describes a parent experiencing difficulty creating
or continuing a nurturing environment for a child. Parental Role Conflict
describes a parent or parents whose previously effective functioning
is challenged by external factors. In certain situations, such as illness,
divorce, or remarriage, role confusion and conflict are expected. If
parents do not receive assistance in adapting their role to external
factors,
Parental Role Conflict can lead to Impaired Parenting.

Goal
The parent/primary caregiver demonstrates two effective skills
to increase parenting effectiveness, as evidenced by the following
indicators:
• Will acknowledge an issue with parenting skills.
• Identify resources available for assistance with improvement of
parenting skills that are culturally considerate.

Interventions
Encourage Parents to Express Frustrations Regarding Role
Responsibilities, Parenting, or Both
• Convey empathy.
• Reserve judgment.
• Convey/offer educational information based on assessment.
• Help foster realistic expectations.
• Encourage discussion of feelings regarding unmet expectations.
• Discuss individualized, achievable, and culturally considerate
strategies (e.g., discussing with partner, child; setting personal
goals).
Educate Parents About Normal Growth and Development and Age-
Related Expected Behaviors (Refer to Delayed Growth and Development)
Explore With Parents the Child’s Problem Behavior
• Frequency, duration, context (when, where, triggers)
• Consequences (parental attention, discipline, inconsistencies in
response)
• Behavior desired by parents
Discuss Positive Parenting Techniques
• Convey to child that he or she is loved.
• Catch child being good; use good eye contact.
• Set aside “special time” when parent guarantees time with
child without interruptions.
• Ignore minor transgressions by having no physical contact, eye
contact, or discussion of the behavior.
• Practice active listening. Describe what child is saying, reflect
back the child’s feelings, and do not judge.
• Parents need to identify the difference between discipline and
punishment, with parents focusing their communications with
children on discipline (Deloian & Berry, 2009).
• Use “I” statements when disapproving of behavior. Focus on
the act, not the child, as undesirable.
• Positive reinforcement is an effective and recommended
discipline technique for all ages (Banks, 2002). Redirecting is
effective for infant to school age, whereas verbal instruction/
explanation is most effective for school-age and adolescents
(Banks, 2002).
• Different child temperaments may challenge parenting behaviors,
as evidenced when an infant is demanding and a parent
lacks resilience or when the child’s behavior is normal and the
parents’ expectations are unrealistic.
Explain the Discipline Technique of “Time Out,” Which Is a
Method to Stop Misconduct, Convey Disapproval, and Provide
Both Parent and Child Time to Regroup (Christophersen, 1992;
Herman-Staab, 1994)
• Time out is most effective for the toddler and school-age child
and provides a time for both parent and child to “cool off”
(Banks, 2002; Hockenberry, 2011).
• Outline the procedure.
• Place child in or bring the child to a chair in a quiet place with
few distractions (not the child’s room or an isolated place).
• Instruct child to stay in the chair. Set timer for 1 minute of
quiet time for each year of age.
• Start the timer when the child is quiet.
• If the child misbehaves, cries, or gets off the chair, reset the
timer.
• When the timer goes off, tell the child it is okay to get up.
• Explain to the child.
• This is not a game.
• Practice it once when the child is behaving.
• Explain rules and then ask the child questions to ensure
understanding (if older than 3 years).
• Remember:
• Do not warn child before sending for time out.
• If time out is appropriate, use it; do not threaten.
• If child laughs during time out, ignore it.
• Be sure no television is on or can be seen.
• Do not look at or talk to or about child during time out.
• Do not act angry; remain calm.
• Keep yourself busy; let the child see you and what he or she
is missing.
• Do not give up or give in.
If Additional Sources of Conflict Arise, Refer to the Specific
Nursing Diagnosis (e.g., Caregiver Role Strain, Fatigue)
Take Opportunities to Model Effective Parenting Skills; If Relevant,
Share Some Frustrations You Have Experienced With Your Child to
Help Normalize the Frustrations
Acknowledge Cultural Impacts
Clarify the Strengths of the Parents or Family
Role-Play Asking for Help or Disciplining a Child
Provide General Parenting Guidelines
Practice open, honest dialogues. Never threaten with vague
parameters
(e.g., “If you are bad, I won’t take you to the movies”).
• Do not lecture. Tell the child he or she was wrong and let it
go. Spend time talking about pleasant experiences.
• Compliment children on their achievements. Make each child
feel important and special. Especially tell a child when he or
she has been good; try not to focus on negative behavior.
• Provide appropriate physical affection to children.
• Set limits and be consistent. Expect cooperation.
• Encourage the child to participate in activities. Let the child
help you as much as possible. “Nurses can encourage parents
in their roles beyond childbearing, help them to solve problems,
perform parenting tasks, and understand what is developmentally
appropriate” (Gage, Everett, & Bullock, 2006).
• Discipline the child by restricting activity. Sit a younger child
in a chair for 3 to 5 minutes. If the child gets up, reprimand
once and put him or her back. Continue until the child sits for
the prescribed time. For an older child, restrict bicycle riding
or going to the movies (pick an activity that is important to
him or her).
• Make sure the discipline corresponds to the unacceptable
behavior.
• Allow children opportunities to make mistakes and to express
anger verbally.
• Stay in control. Try not to discipline when you are irritated.
• When long explanations are needed, give them after the
discipline.
• Remember to examine what you are doing when you are not
disciplining your child (e.g., enjoying each other, loving each
other).
• Never reprimand a child in front of another person (child or
adult). Take the child aside and talk.
• Never decide you cannot control a child’s destructive behavior.
Examine your present response. Are you threatening? Do you
follow through with the punishment or do you give in? Has
the child learned you do not mean what you say?
• Be a good model (the child learns from you whether you
intend it or not). Never lie to a child even when you think it
is better; the child must learn that you will not lie, no matter
what.
• Give each child a responsibility suited to his or her age, such
as picking up toys, making beds, or drying dishes. Expect the
child to complete the task.
• Share your feelings with children (happiness, sadness, anger).
Respect and be considerate of the child’s feelings and of his or
her right to be human.
Initiate Health Teaching and Referrals, as Indicated
• Community resources such as counseling, social services,
parenting classes, support groups, self-help, church.
• Support cultural considerations of parenting skills as age
appropriate.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

IMBALANCED NUTRITION: MORE THAN BODY REQUIREMENTS Nursing Care Plan

Imbalanced Nutrition: More Than Body Requirements
Intake of nutrients that exceeds metabolic needs
Defining Characteristics
Major (Must Be Present, One or More)
Overweight (weight 10% over ideal for height and frame), or
Obese (weight 20% or more over ideal for height and frame)*
Triceps skinfold greater than 15 mm in men and 25 mm in women*
Minor (May Be Present)
Reported undesirable eating patterns
Intake in excess of metabolic requirements
Sedentary activity patterns
Related Factors
Pathophysiologic
Related to excessive intake in relation to metabolic needs*
Related to altered satiety patterns secondary to (specify)
Related to decreased sense of taste and smell
Treatment Related
Related to altered satiety secondary to:
Medications (corticosteroids, antihistamines, estrogens)
Radiation (decreased sense of taste and smell)
Situational (Personal, Environmental)
Related to stress
Related to overeating
Related to dysfunctional eating pattern (e.g., pairing with other activities,
fast foods)
Related to risk to gain more than 25 to 30 lb when pregnant
Related to lack of basic nutrition knowledge

Author's Notes
Using this diagnosis to describe people who are overweight or obese places
the focus of interventions on nutrition. Obesity is a complex condition with
sociocultural, psychological, and metabolic implications. When the focus is
primarily on limiting food intake, as with many weight-loss programs, the
chance of permanent weight loss is slim. To be successful,
a weight-loss
program must focus on behavior modification and lifestyle changes.
The nursing diagnosis Imbalanced Nutrition: More Than Body
Requirements does not describe this focus. Rather, Risk-Prone Health
Behavior related to intake in excess of metabolic requirements better
reflects the need to increase metabolic requirements through exercise and
decreased intake. For some people who desire weight loss, Ineffective
Coping related to increased eating in response to stressors could be useful
in addition to Risk-Prone Health Behavior.
The nurse should be cautioned against applying a nursing diagnosis
for an overweight or obese person who does not want to participate
in a weight-loss program. Motivation for weight loss must come from
within. Nurses can gently and expertly teach the hazards of obesity but
must respect a client’s right to choose—the right of self-determination.
Imbalanced Nutrition: More Than Body Requirements does have clinical
usefulness for people at risk for or who have experienced weight gain
because of pregnancy, taste or smell changes, or medications
(e.g., corticosteroids).

Goal
The person will describe why he or she is at risk for weight gain as
evidenced by the following indicators:
• Describe reasons for increased intake with taste or olfactory
deficits.
• Discuss the nutritional needs during pregnancy.
• Discuss the effects of exercise on weight control.

Interventions
Refer to Related Factors
Explain the Effects of Decreased Sense of Taste and Smell on
Perception of Satiety After Eating. Encourage Client to:
• Evaluate intake by calorie counting, not feelings of satiety.
• If not contraindicated, season foods heavily to satisfy decreased
sense of taste. Experiment with seasonings (e.g., dill, basil).
• When taste is diminished, concentrate on food smells.
Explain the Rationale for Increased Appetite Owing to Use of
Certain Medications (e.g., Steroids, Androgens)
Discuss Nutritional Intake and Weight Gain During Pregnancy
Assist Client to Decrease Calorie Intake
• Request that client write down all the food he or she ate in the
past 24 hours.
• Instruct client to keep a diet diary for 1 week that specifies the
following:
• What, when, where, and why eaten
• Whether he or she was doing anything else (e.g., watching
television, cooking) while eating
• Emotions before eating
• Others present (e.g., snacking with spouse, children)
• Review the diet diary to point out patterns (e.g., time, place,
emotions, foods, persons) that affect food intake.
• Review high- and low-calorie food items.
Teach Behavior Modification Techniques to Decrease
Caloric Intake
• Eat only at a specific spot at home (e.g., the kitchen table).
• Do not eat while performing other activities.
• Drink an 8-oz glass of water immediately before a meal.
• Decrease second helpings, fatty foods, sweets, and alcohol.
• Prepare small portions, just enough for one meal, and discard
leftovers.
• Use small plates to make portions look bigger.
• Never eat from another person’s plate.
• Eat slowly and chew food thoroughly.
• Put down utensils and wait 15 seconds between bites.
• Eat low-calorie snacks that must be chewed to satisfy oral
needs (e.g., carrots, celery, apples).
Instruct Client to Increase Activity Level to Burn Calories
• Use the stairs instead of elevators.
• Park at the farthest point in parking lots and walk to buildings.
• Plan a daily walking program with a progressive increase in
distance and pace.
• Note: Urge client to consult with a primary provider before
beginning any exercise program.
Initiate Referral to a Community Weight Loss Program (e.g.,
Weight Watchers), If Indicated

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

IMPAIRED SWALLOWING Nursing Care Plan

Impaired Swallowing
Abnormal functioning of the swallowing mechanism associated
with deficits in oral, pharyngeal, or esophageal structure or function

Defining Characteristics
Major (Must Be Present, One or More)*
Observed evidence of difficulty in swallowing and/or:
Stasis of food in oral cavity
Coughing before a swallow
Coughing after food or fluid intake
Choking
Gagging
Minor (May Be Present)
Nasal-sounding voice
Drooling*
Slurred speech
Vomiting*
Regurgitation*
Lack of chewing*
Related Factors
Pathophysiologic
Related to decreased/absent gag reflex, mastication difficulties, or decreased
sensations secondary to:
Cerebral palsy*
Muscular dystrophy
Poliomyelitis
Parkinson’s disease
Guillain–Barré syndrome
Myasthenia gravis
Amyotrophic lateral sclerosis
CVA
Neoplastic disease affecting
brain
Right or left hemispheric brain
damage
Vocal cord paralysis
Cranial nerve damage (V, VII,
IX, X, XI)
Related to tracheoesophageal tumors, edema
Related to irritated oropharyngeal cavity
Related to decreased saliva
Treatment Related
Related to surgical reconstruction of the mouth, throat, jaw, or nose
Related to decreased consciousness secondary to anesthesia
Related to mechanical obstruction secondary to tracheostomy tube
Related to esophagitis secondary to radiotherapy
Situational (Personal, Environmental)
Related to fatigue
Related to limited awareness, distractibility
Maturational
Infants/Children
Related to decreased sensations or difficulty with mastication
Related to poor suck/swallow/breathe coordination
Older Adult
Related to reduction in saliva, taste

Goal
The client will report improved ability to swallow, as evidenced by
the following indicators:
• Describe causative factors when known.
• Describe rationale and procedures for treatment.

Interventions
Assess for Causative or Contributing Factors
Refer to Related Factors.
• Consult with a speech therapist for a bedside swallowing
assessment
and recommended plan of care.
• Alert all staff that client has impaired swallowing.
Reduce or Eliminate Causative/Contributing Factors in People With:
Mechanical Impairment of Mouth
• Assist client with moving the bolus of food from the anterior to
the posterior part of mouth. Place food in the posterior mouth,
where swallowing can be ensured, using:
• A syringe with a short piece of tubing attached
• A glossectomy spoon
• Soft, moist food of a consistency that can be manipulated by
the tongue against the pharynx, such as gelatin, custard, or
mashed potatoes.
• Prevent/decrease thick secretions with:
• Artificial saliva Papain tablets dissolved in mouth 10 minutes
before eating
• Meat tenderizer made from papaya enzyme applied to oral
cavity 10 minutes before eating
• Frequent mouth care
• Increase fluid intake to 8 glasses of liquid (unless contraindicated)
• Check medications for potential side effects of dry mouth/
decreased salivation
• Use of Haberman or comparable nipple when bottle feeding
for infant with cleft lip/palate and Möbius syndrome
Muscle Paralysis or Paresis
• Establish a visual method to communicate with staff at bedside
that client is dysphagic.
• Plan meals when client is well rested; ensure that reliable
suction equipment is on hand during meals. Discontinue feeding
if client is tired.
• If indicated, use modified supraglottic swallow technique
(Emick-Herring & Wood, 1990).
• Position the head of the bed in semi- or high Fowler’s position,
with the neck flexed forward slightly and chin tilted down.
• Use cutout cup (remove and round out one third of side of
foam cup).
• Take bolus of food and hold in strongest side of mouth for
1 to 2 seconds, then immediately flex the neck with chin
tucked against chest.
• Without breathing, swallow as many times as needed.
• When mouth is emptied, raise chin and clear throat.
• Note the consistency of food that is problematic. Select
consistencies that are easier to swallow, such as:
• Highly viscous foods (e.g., mashed bananas, potatoes,
gelatin, gravy)
• Thick liquids (e.g., milkshakes, slushes, nectars, cream soups)
• If drooling is present, use a quick-stretch stimulation just before
and toward the end of each meal (Emick-Herring & Wood, 1990):
• Digitally apply short, rapid, downward strokes to edge of
bottom lip, mostly on the affected side.
• Use a cold washcloth over finger for added stimulation.
• If a bolus of food is pocketed in the affected side, teach client
how to use tongue to transfer food or apply external digital
pressure to cheek to help remove the trapped bolus (Emick-
Herring & Wood, 1990).
Impaired Cognition or Awareness
General
• Remove feeding tube during training if increased gag reflex is
present.
• Concentrate on solids rather than liquids because liquids usually
are less well tolerated.
• Minimize extraneous stimuli while eating (e.g., no television or
radio, no verbal stimuli unless directed at task).
• Have client concentrate on task of swallowing.
• Have client sit up in chair with neck slightly flexed.
• Instruct client to hold breath while swallowing.
• Observe for swallowing and check mouth for emptying.
• Avoid overloading mouth because this decreases swallowing
effectiveness.
• Give solids and liquids separately.
• Progress slowly. Limit conversation.
• Provide several small meals to accommodate a short attention
span.
Client With Aphasia or Left Hemispheric Damage
• Demonstrate expected behavior.
• Reinforce behaviors with simple, one-word commands.
Client With Apraxia or Right Hemispheric Damage
• Divide task into smallest units possible.
• Assist through each task with verbal commands.
• Allow to complete one unit fully before giving next command.
• Continue verbal assistance at each eating session until no
longer needed.
• Incorporate written checklist as a reminder to client.
• Note: Client may have both left and right hemispheric damage
and require a combination of the above techniques.
Reduce the Possibility of Aspiration
• Before beginning feeding, assess that the client is adequately
alert and responsive, can control the mouth, has cough/gag
reflex, and can swallow saliva.
• Have suction equipment available and functioning properly.
• Position client correctly:
• Sit client upright (60 to 90 degrees) in chair or dangle his or her
feet at side of bed if possible (prop with pillows if necessary).
• Client should assume this position 10 to 15 minutes before
eating and maintain it for 10 to 15 minutes after finishing
eating.
• Flex client’s head forward on the midline about
45 degrees to keep esophagus patent.
• Keep infant’s head elevated during and immediately after
feedings
• Keep client focused on task by giving directions until he or she
has finished swallowing each mouthful.
• “Take a breath.”
• “Move food to middle of tongue.”
• “Raise tongue to roof of mouth.”
• “Think about swallowing.”
• “Swallow.”
• “Cough to clear airway.”
• Reinforce voluntary action.
• Start with small amounts and progress slowly as client learns to
handle each step:
• Ice chips
• Eyedropper partly filled with water
• Whole eyedropper filled with water
• Juice in place of water
• ¼ teaspoon semisolid food
• ½ teaspoon semisolid food
• 1 teaspoon semisolid food
• Pureed or commercial baby foods
• One half cracker
• Soft diet
• Regular diet; chew food well
• For a client who has had a CVA, place food at back of tongue
and on side of face he or she can control:
• Feed slowly, making certain client has swallowed the
previous
bite.
• Some clients do better with foods that hold together
(e.g., soft-boiled eggs, ground meat and gravy).
• If the above strategies are unsuccessful, consultation with a
physician may be necessary for alternative feeding techniques
such as tube feedings or parenteral nutrition.
Initiate Health Teaching and Referrals, as Indicated
Teach Exercises to Strengthen (Grober, 1984):
Lips and Facial Muscles
• Alternate a tight frown with a broad smile with lips closed.
• Puff out cheeks with air and hold.
• Blow out of pursed lips.
• Practice pronouncing u, m, b, p, w.
• Suck hard on a popsicle.
Tongue
• Lick a popsicle or lollipop.
• Push tip of tongue against roof and floor of mouth.
• Count teeth with tongue.
• Pronounce la, la, la; ta, ta, ta; d; n; z; s.
• See Impaired Oral Mucous Membranes.
• See Imbalanced Nutrition: Less Than Body Requirements.

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IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Nursing Care Plan

Imbalanced Nutrition: Less Than Body Requirements
Intake of nutrients insufficient to meet metabolic needs

Major (Must Be Present, One or More)
The client who is not NPO reports or is found to have food intake
less than the recommended daily allowance (RDA) with or without
weight loss
and/or
Actual or potential metabolic needs in excess of intake with
weight loss
Minor (May Be Present)
Weight 10% to 20% or more below ideal for height and frame
Triceps skinfold, mid-arm circumference, and mid-arm muscle
circumference less than 60% standard measurement
Muscle weakness and tenderness
Mental irritability or confusion
Decreased serum albumin
Decreased serum transferrin or iron-binding capacity
Sunken fontanel in infant
Related Factors
Pathophysiologic
Related to increased caloric requirements and difficulty in ingesting
sufficient
calories secondary to:
Burns (postacute phase)
Cancer
Infection
Trauma
Chemical dependence
Preterm infants
Gastrointestinal (GI)
complications/deformities
AIDS
Related to dysphagia secondary to:
Cerebrovascular accident
(CVA)
Parkinson’s disease
Möbius syndrome
Muscular dystrophy
Cerebral palsy
Cleft lip/palate
Amyotrophic lateral sclerosis
Neuromuscular disorders
Related to decreased absorption of nutrients secondary to:
Crohn’s disease
Lactose intolerance
Necrotizing enterocolitis
Cystic fibrosis
Related to decreased desire to eat secondary to altered level of consciousness
Related to self-induced vomiting, physical exercise in excess of caloric
intake, or refusal to eat secondary to anorexia nervosa
Related to reluctance to eat for fear of poisoning secondary to paranoid
behavior
Related to anorexia, excessive physical agitation secondary to bipolar
disorder
Related to anorexia and diarrhea secondary to protozoal infection
Related to vomiting, anorexia, and impaired digestion secondary to
pancreatitis
Related to anorexia, impaired protein and fat metabolism, and impaired
storage of vitamins secondary to cirrhosis
Related to anorexia, vomiting, and impaired digestion secondary to
GI malformation or necrotizing enterocolitis
Related to anorexia secondary to gastroesophageal reflux
Treatment Related
Related to protein and vitamin requirements for wound healing and
decreased intake secondary to:
Surgery
Surgical reconstruction of
mouth
Radiation therapy
Medications (chemotherapy)
Wired jaw
Related to inadequate absorption as a medication side effect of (specify):
Colchicine
Neomycin
Pyrimethamine
Para-aminosalicylic acid
Antacid
Related to decreased oral intake, mouth discomfort, nausea, and vomiting
secondary to:
Radiation therapy
Tonsillectomy
Chemotherapy
Oral trauma
Situational (Personal, Environmental)
Related to decreased desire to eat secondary to:
Anorexia
Social isolation
Depression
Nausea and vomiting
Stress
Allergies
Related to inability to procure food (physical limitation or financial
or transportation problems)
Related to inability to chew (damaged or missing teeth, ill-fitting
dentures)
Related to diarrhea* secondary to (specify)
Maturational
Infant/Child
Related to inadequate intake secondary to:
Lack of emotional/sensory
stimulation
Lack of knowledge of caregiver
Inadequate production of
breast milk
Related to malabsorption, dietary restrictions, and anorexia secondary to:
Celiac disease
Lactose intolerance
Necrotizing enterocolitis
Cystic fibrosis
GI malformation
Gastroesophageal reflux
Related to sucking difficulties (infant) and dysphagia secondary to:
Cerebral palsy
Cleft lip and palate
Neurologic impairment
Related to inadequate sucking, fatigue, and dyspnea secondary to:
Congenital heart disease
Viral syndrome
Hyperbilirubinemia
Prematurity
Respiratory distress syndrome
Developmental delay

Author's Notes
Nurses are usually the primary diagnosticians and often the prescribers
for improving nutritional status. Although Imbalanced Nutrition is not a
difficult diagnosis to validate, interventions for it can challenge the nurse.
Many factors influence food habits and nutritional status: personal,
family, cultural, financial, functional ability, nutritional knowledge, disease
and injury, and treatment regimens. Imbalanced Nutrition: Less Than Body
Requirements describes people who can ingest food but eat an inadequate
or imbalanced quality or quantity. For instance, the diet may have
insufficient protein or excessive fat. Quantity may be insufficient because
of increased metabolic requirements (e.g., cancer, pregnancy, trauma,
or interference with nutrient use [e.g., impaired storage of vitamins in
cirrhosis]).
The nursing focus for Imbalanced Nutrition is assisting the client or
family to improve nutritional intake. Nurses should not use this diagnosis
to describe clients who are NPO or cannot ingest food. They should use
the collaborative problems RC of Electrolyte Imbalance or RC of Negative
Nitrogen Balance to describe those situations.

Goal
The client will ingest daily nutritional requirements in accordance
with activity level and metabolic needs, as evidenced by the
following
indicators:
• Relate importance of good nutrition.
• Identify deficiencies in daily intake.
• Relate methods to increase appetite.

Interventions
Explain the Need for Adequate Consumption of Carbohydrates,
Fats, Protein, Vitamins, Minerals, and Fluids
Consult With a Nutritionist to Establish Appropriate Daily Caloric
and Food Type Requirements for the Client
Discuss With the Client Possible Causes of Decreased Appetite
Encourage the Client to Rest Before Meals
Offer Frequent, Small Meals Instead of a Few Large Ones; Offer
Foods Served Cold
With Decreased Appetite, Restrict Liquids With Meals and Avoid
Fluids 1 Hour Before and After Meals
Encourage and Help the Client to Maintain Good Oral Hygiene
Arrange to Have High-Calorie and High-Protein Foods Served at
the Times That the Client Usually Feels Most Like Eating
Take Steps to Promote Appetite
• Determine the client’s food preferences and arrange to have
them provided, as appropriate.
• Eliminate any offensive odors and sights from the eating area.
• Control any pain and nausea before meals.
• Encourage the client’s family to bring permitted foods from
home, if possible.
• Provide a relaxed atmosphere and some socialization during
meals.
Provide for Supplemental Dietary Needs Amplified by Acute Illness
Give the Client Printed Materials Outlining a Nutritious Diet That
Includes the Following:
• High intake of complex carbohydrates and fiber
• Decreased intake of sugar, salt, cholesterol, total fat, and
saturated
fats
• Alcohol use only in moderation
• Proper caloric intake to maintain ideal weight
Pediatric Interventions
• Teach parents the following regarding infant nutrition:
• Adequate infant feeding schedule and weight gain requirements
for growth: 100 to 120 kcal/kg/day for growth
• Proper preparation of infant formula
• Proper storage of breast milk and infant formula
• Proper elevation of infant’s head during and immediately after
feedings
• Proper chin/cheek support techniques for orally compromised
infants
• The age-related nutritional needs of their children (consult
an appropriate textbook on pediatrics or nutrition for specific
recommendations).
• Discuss the importance of limiting snacks high in salt, sugar, or
fat (e.g., soda, candy, chips) to limit risks for cardiac disorders,
obesity, and diabetes mellitus. Advise families to substitute
healthy snacks (e.g., fresh fruits, plain popcorn, frozen fruit
juice bars, fresh vegetables).
• Assist families in evaluating their nutritional patterns.
• Discuss strategies to make meals a social event and to avoid
struggles (Dudek, 2009; Hockenberry & Wilson, 2009).
• Allow the child to select one type of food he or she does not
have to eat.
• Provide small servings (e.g., one tablespoon of each food for
every year of age).
• Make snacks as nutritiously important as meals (e.g., hardboiled
eggs, raw vegetable sticks, peanut butter/crackers, fruit
juices, cheese, and fresh fruit).
• Offer a variety of foods.
• Encourage all members to share their day.
• Involve the child in monitoring healthy eating (e.g., create a
chart where the child checks off intake of healthy foods daily).
• Replace passive television watching with a group activity (e.g.,
Frisbee tossing, biking, walking).
• Address strategies to improve nutrition when eating fast foods:
• Drink skim milk.
• Avoid french fries.
• Choose grilled foods.
• Eat salads and vegetables.
• Substitute quick, nutritious fast meals (e.g., frozen dinners).
Maternal Interventions
• Teach the importance of adequate calorie and fluid intake
while breastfeeding in relation to breast milk production.
• Explain physiologic changes and nutritional needs during
pregnancy.
Discuss the effects of alcohol, caffeine, and artificial sweeteners
on the developing fetus.
• Explain the different nutritional requirements for pregnant
girls 11 to 18 years of age, pregnant young women 19 to
24 years of age, and women older than 25 years.
• Determine if a woman needs more calories because of daily
activity.
• 28.5 kcal/kg for 11 to 14 years
• 24.9 kcal/kg for 15 to 18 years
• 23.3 kcal/kg for 19 to 24 years
• 21.9 kcal/kg for 25 to 50 years
• Multiply resting caloric needs by:
• 1.5 for light activity
• 1.6 for moderate activity
• 1.9 for heavy activity
Geriatric Interventions
Determine the Client’s Understanding of Nutritional Needs With:
• Aging
• Medication use
• Illness
• Activity
Assess Whether Any Factors Interfere With Procuring or Ingesting
Foods (Miller, 2009)
• Anorexia from medications, grief, depression, or illness
• Impaired mental status leading to inattention to hunger or
selecting insufficient kinds/amounts of food
• Impaired mobility or manual dexterity (paresis, tremors,
weakness, joint pain, or deformity)
• Voluntary fluid restriction for fear of urinary incontinence
• Small frame or history of undernutrition
• Inadequate income to purchase food
• Lack of transportation to buy food or facility to cook
• New dentures or poor dentition
• Dislike of cooking and eating alone
• Client regularly eats alone
• Client has more than two alcoholic drinks daily
Explain Decline in Sensitivity to Sweet and Salty Tastes; If
Indicated, Consult With Home Health Nurse to Evaluate Home
Environment (e.g., Cooking Facilities, Food Supply, Cleanliness)
Access Community Agencies as Indicated (e.g., Nutritional
Programs, Community Centers, Home-Delivered Grocery Services)

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!